It can all look good on the map. The pathway seems clear. You have a system – what can go wrong on the way from here to there? It is only when looking closely – or when trying to work out why you are in the wrong place – that the complexity becomes apparent, and the weaknesses inherent in the system obvious. The road that you planned to take is blocked by an accident, the side street which you then find as a way out is clogged by parked cars, and then everyone decides to use the bus lane to keep more lanes of traffic moving.
Ideally a health system functions to get the right patient, the right treatment at the right time. Again, it all sounds simple. However, we all have experiences in our clinic that do not follow the map. Even with potentially serious presentations it may not work, and can actually start before we even get on our map. The condition needs to cause a symptom, which is at times surprisingly late. Each of us has probably had an experience of making a diagnosis of a significant illness, such as a malignancy, and being surprised by the high level of function and limited symptoms the patient has experienced, even when the pathology is extensive.
The symptom needs to be recognised by the patient as potentially serious – or at least concerning enough to consult their general practitioner about. The threshold of different individuals for what they feel is worth making an appointment (or in some cases ‘bothering the doctor’ about) varies. Take bowel cancer: bleeding may provoke many people to seek a medical opinion, other presentations such as vague pain, change in bowel habit, or loss of weight may not lead to the same speed in making an appointment.
So the patient has arrived at the clinic, the GP assesses the problem and recognises that it may be a serious condition. Once again, it sounds simple, but diagnostic errors do occur. The GP decides this is potentially serious and needs to convey this in a referral to a hospital, how it is communicated in the letter determines how soon the patient is seen by the next step in the system, and how that ecosystem is working can also influence the waiting time. None of this allows for other risks that we run systems to attempt to mitigate, such as no appointment for the patient as the referral got lost en route from GP to the right person in the hospital. While it all started as a simple pathway with potentially sinister symptoms that need timely investigation to diagnose or exclude a malignancy, it is now clear just how many elements the pathway has, and the number of potential traffic jams and side streets to get stuck in. Interestingly, GPs probably intuitively know this, as research on referral pathways for patients with colorectal cancer provided data that when worried, GPs would call the surgeon,1 which removes many of the possible bottlenecks, however, this is not always possible.
Arteries and veins can be seen as the road system of the body. In anatomical diagrams they are the highways of red and blue lines leading to all parts of the body. They are the pathways for blood around the body, ideally at the ‘right’ pressure.
Blood pressure is something that we GPs make decisions about every day. It can be seen as a routine part of clinical practice. Take blood pressure and then do something if needed. However, it is a more complex situation than that. We know the decision to commence treatment is relatively straightforward; it is the issues around what the true underlying blood pressure, measurement and the individual patient can be more complicated.2
In this issue of Australian Family Physician, O’Callaghan and colleagues focus on some of the more difficult decisions in regards to hypertension.3 Robinson and colleagues consider aortic aneurysms, and provide us with an update on screening, surveillance and management.4 There is clear guidance on surveillance intervals and indications for surgery. Aneurysms can occur in other sites, and the article by Mees and colleagues consider these – some of which, such as splanchnic aortic aneurysms, are usually asymptomatic, but if they rupture are life-threatening.5 Sometimes the problem occurs on the return journey and varicose veins are the topic of the article by Wright and Fitridge.6
We hope you enjoy navigating your way through this issue of AFP, as we offer information and pathways that may help you in your every day clinical practice.
- Harris MF, Pascoe S, Crossland L, et al. Patients with colorectal cancer: a qualitative study of referral pathways and continuing care. Aust Fam Physician 2012;41:899–902.
- Howes F, Hansen E, Williams D, Nelson M. Barriers to diagnosing and managing hypertension: a qualitative study in Australian general practice. Aust Fam Physician 2010;39:511–6.
- O’Callaghan CJ, Goh MY, Rong P. Hypertension: the difficult decisions. Aust Fam Physician 2013;43:376–9.
- Robinson D, Mees B, Verhagen H, Chuen J. Aortic aneurysms: screening, surveillance and referral.
Aust Fam Physician 2013;43:364–9.
- Mees B, Robinson D, Verhagen H, Chuen J. Non-aortic aneurysms: natural history and recommendations for referral and treatment. Aust Fam Physician 2013;43:370–4.
- Wright N, Fitridge R. Varicose veins: natural history, assessment and management. Aust Fam Physician 2013;43:380–4.